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course, if something treatable turns up (such as a tumor or virus), you will no doubt require further therapy.

Abscess and Fistula-in-Ano
     
    An abscess in your anal region is potentially very dangerous, yet often gay men ignore it until it progresses to a critical stage. An abscess begins as a painful sensation in your anal area, which gay men often wrongly attribute to a prior sexual experience. Embarrassment keeps them from seeing a physician while their infection is still in its early stages. Although the infection certainly could be caused by injury during sex, most often it results from a piece of stool getting caught in your anal crypts (glands). (See Figure 2. 1 . ) This earliest painful stage is called a
cryptitis.
As infection progresses, it can spread into sphincter muscles and fatty tissue around the anus and rectum. The infection forms a cavity and pus accumulates. At this point you have what is commonly called a perirectal abscess.
    Once an abscess develops, it burrows toward the skin, slowly destroying more and more tissue. Your skin reddens, is warm to the touch, and may feel like a water balloon if you gently push on it. Of course, any pressure to the area is very painful. If a doctor does not intervene, eventually your abscess will break through the skin and pus will pour out. Although you’ll feel better immediately, your problem won’t be solved, because the hole is not large enough to drain the cavity fully. Pus reaccumulates until it drains again, but the unabated infection destroys more and more surrounding tissue, including, occasionally, the sphincters. I have treated patients whose infection left them unable to control their bowels.
    Proper treatment for a perirectal abscess is surgical and is called an I&D (incision and drainage). While antibiotics often are necessary, by themselves they are not enough. Local anesthesia for surgery won’t provide adequate relief. Ask to either go to sleep (general anesthesia) or have regional anesthesia that numbs your lower body. Most people feel much better after their surgery.
    I treated a young man who noticed severe rectal pressure several days after anal sex. He assumed that his problem was related to something that happened during sex and put off seeing a physician until he had a high fever and could barely walk. In his case, the abscess had traveled upward along his colon rather than out toward his skin. His abscess required multiple surgeries over more than two years until it was completely cured.
    A fistula-in-ano can result from a prior abscess but is more often caused by a milder infection that never formed a full-blown cavity. Instead, the infection burrowed to your skin and popped open like a pimple. (See Figure 2. 1 . ) Again, it is
rarely
related to a previous sexual experience. Most men complain of a tiny painful pimple or boil beside their anal opening that swells until it drains a bit of pus. Symptoms are rarely severe enough to see a doctor and may go away for days to months at a time until the cycle begins again.
    A fistula-in-ano should be treated. If it blocks up and cannot drain, an abscess will develop. Some men have fistulas that form side tracks that spread around their anus making multiple holes (commonly called a watering-can anus). I have seen men with holes so large that stool came out of them when they moved their bowels. Not a pretty sight.
    Surgery is the best treatment and involves opening the fistula (performing a fistulotomy) and removing debris so it can heal from the inside out. Usually discomfort after surgery is minimal. If the fistula is large and travels through sphincter muscles, incontinence is possible after surgery. In these cases, the surgery is much more complicated and done in stages. Occasionally, if faced with a very difficult fistula, a surgeon might recommend that it be left alone. Fortunately these extreme conditions are rare.

Anal Pruritus (Itch)
     
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